NCLEX-RN
NCLEX RN Exam Prep
1. Your elderly patient has a temperature of 98.5 degrees. Is there anything else that a nurse should do, in addition to documenting this temperature?
- A. No, this temperature is within normal limits.
- B. No, this temperature is normally hyperthermic.
- C. Yes, this temperature is highly hyperthermic.
- D. Yes, this temperature is highly hypothermic.
Correct answer: A
Rationale: No, there is nothing else that a nurse should do. A temperature of 98.5 degrees for an elderly patient falls within normal limits. Other choices are incorrect because the temperature is not hyperthermic (abnormally high) or hypothermic (abnormally low), making choices B, C, and D inaccurate responses in this scenario.
2. To collect timely, specific information, the nurse is most likely to ask which of the following questions?
- A. Would you describe what you are feeling?
- B. How are you today?
- C. What would you like to talk about?
- D. Where does it hurt?
Correct answer: A
Rationale: The correct answer is, 'Would you describe what you are feeling?' This open-ended question prompts the patient to provide subjective data, offering specific information about their current health status and human responses. This information can help identify actual or potential health issues. Choices B and C are more likely to yield general, nonspecific information. Choice D may lead to a brief response or nonverbal indication of pain location. A more effective approach to gather specific information about pain would be to ask, 'Can you describe any pain you are experiencing?'
3. Which of the following descriptions best describes the function of the thyroid gland?
- A. The thyroid gland converts glucose into glycogen
- B. The thyroid gland secretes cortisol during times of stress
- C. The thyroid gland regulates body metabolism
- D. The thyroid gland affects skin pigmentation
Correct answer: C
Rationale: The thyroid gland is responsible for secreting thyroxine (T4) and triiodothyronine (T3), which work to regulate the metabolism of the body's cells. The primary function of the thyroid gland is to control the body's metabolic rate, affecting processes such as heart rate, temperature regulation, and energy levels. Choices A, B, and D are incorrect because the thyroid gland is not involved in converting glucose into glycogen, secreting cortisol, or affecting skin pigmentation. Instead, the primary role of the thyroid gland is to regulate the metabolism and energy balance in the body.
4. A healthcare professional is preparing to administer a dose of platelets to a client. Which of the following actions must the healthcare professional perform before giving the platelets?
- A. Start an IV of 0.9% Normal Saline to administer with the platelets
- B. Ensure the container with the platelets is intact and not damaged
- C. Verify the client's identity using two unique identifiers
- D. Check the client's chart to ensure no contraindications to platelet transfusion
Correct answer: B
Rationale: Before administering platelets, it is crucial to check the integrity of the container holding the blood product. An intact container ensures the sterility and safety of the platelets, minimizing the risk of contamination or infection. Option A is incorrect as administering platelets typically does not require starting a new IV line unless indicated for the specific patient. Option C is not the priority as verifying the client's identity can be done at any point during the administration process but is not specific to the platelet transfusion itself. Option D, checking the client's chart for antibiotic use, is not directly related to ensuring the safety of the blood product container.
5. What is the BEST blood collection location for a newborn?
- A. the AC
- B. the veins of the forehead
- C. the heel
- D. the fingertips
Correct answer: C
Rationale: When collecting blood from newborns, it is safest and most commonly done by collecting blood from the lateral or medial aspect of the baby's heel. This location is preferred due to the accessibility of the veins and the minimal discomfort caused to the newborn. Veins in the forehead are not commonly used for blood collection in newborns. The fingertips are not optimal for blood collection in newborns due to their small size and the potential for causing discomfort. The AC (antecubital) area, typically used in adults for blood collection, is not recommended for newborns due to the size of their veins and the potential risk of injury.
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